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THE FUSE MODEL
Discussion of Blueprint:
Concept of 3 pillars with the 9 steps

CSH’s work with communities implementing FUSE nationwide has led to the development of a conceptual framework, or Blueprint, for developing, implementing and scaling FUSE programs. While CSH has helped each of the communities implementing FUSE to adapt the model to suit its unique local contexts and conditions, at the core of FUSE are three essential pillars:

Data driven problem solving; policy and systems reform; targeted housing and services.

Data-Driven
Problem Solving

Policy & Systems Reform

Targeted Housing & Services

Cross-System data match to identify users Convene interagency and multi-sector working group Create supportive housing & develop assertive recruitment process
Track Implementation Progress

 

Troubleshoot barriers to housing placement & retention Recruit and place clients into housing, and stabilize with services 
Measure outcomes/impact and cost effectiveness Enlist Policy Makers to bring FUSE to scale Expand model and house additional clients

(Click on the steps above to jump to that section of the Model)

Data Driven Problem-Solving
Data is used to identify a specific target population of high-cost, high-need individuals who are shared clients of multiple systems (jails, homeless shelters and crisis health services) and whose persistent cycling indicates the failure of traditional approaches. Data is also used to develop a new shared definition of success that takes into account both human and public costs, and where the focus is on avoiding institutions altogether, as opposed to simply offloading clients from one system to another.

Policy & Systems Reform
Public systems and policymakers are engaged in a collective effort to address the needs of shared clients and to shift resources away from costly crisis services and towards a more cost-effective and humane solution: permanent housing and supportive services.

Targeted Housing Services
Supportive housing—permanent housing linked to individualized supportive services—is enhanced with targeted and assertive recruitment through in-reach into jails, shelters, hospitals and other settings, in order to help clients obtain housing stability and avoid returns to costly crisis services and institutions.


Following the 9 Steps to a Successful FUSE

The following are the steps across the three pillars, the process for identifying your target population, gathering the political and community support, identifying housing and services and then finally, housing placement and program implementation.

While presented sequentially, many communities work through multiple steps simultaneously. However, the first three steps are critical to the success of the remaining steps as they create the foundation from which you can build a FUSE program.


Using a Cross System Data Match to Identify Frequent Users

FUSE focuses on deep targeting to achieve maximum impact in system use reduction. Thus, it is important to start with identifying a community’s frequent users. Match administrative data across corrections, homeless services and other crisis public services to develop a list of shared clients who meet specified thresholds of high service use (e.g. 4 jail and 4 shelter admissions in last 5 years, with at least one in each system in the past year).

The match helps to identify the scale and scope of overlap between incarceration or hospitalization and homelessness, and ID the target population. This data is powerful in convincing future stakeholders – many in siloed agencies -- why this issue matters to them.

In order to the greatest impact in reducing system use and realizing cost savings, FUSE programs need to be focused on the highest cost users – those cycling in and out of jails, shelters, detox, emergency rooms, and other high cost services.

Results of cross systems data match Finding that a small portion of people are taking up a disproportionately large amount of resources is common in communities looking at frequent users. Many efforts nationally have found this to be true, and is often referred to as the “5:50” rule – 5% of people consume 50% or more of the public resources.

In terms of finding your community’s frequent users, the results of a match will help not only ID who you need to target for housing; it can also determine the size of the housing program. The results will indicate the depth of the need and how to create eligibility criteria for housing.

Example: A number of FUSE programs that focus on homeless frequent users of local jails have used a “4 stays in 5 years” criteria for program eligibility, including NYC FUSE and MeckFUSE. For these programs, the eligibility criteria for the program is at least 4 stays in each system over the past 5 years, with at least one stay in each in the most recent year before the data match. Often, a behavioral health condition, substance use disorder, or other disability (typically broadly defined) is added to the criteria.

Bumps in the road, it happens!
Data matches are easy to dream about but often hard to execute in reality. There may be concerns around sharing protected information between agencies. Solutions to this can include:

  • Data flowing from the least protected to the most stringent, so from a correction system to homeless system like HMIS, then on to the health system if needed.
  • Use an external researcher, for example from a local university who is neutral to the involved agencies.
  • Have involved systems cull their own “frequent users” defined however they see fit and have a selected analyst, either internal or external, match those people.
    Example: Project 25 in San Diego - between hospitals, jail, and ambulance data and found that among the overlapping people nearly all were homeless. Thus, having homeless data/HMIS may not always be strictly necessary.

Sharing considerations
When sharing data across agencies, it is important to set parameters that layout the process and ensure the security of the information shared. Considerations include drafting a Memorandum of Understanding (MOU), business agreement, or scope of work (SOW) that detail the roles and responsibility of each partner and creating a secure file transfer system.

Other ways of data driven targeting include
Let’s be honest, many agencies from the homeless and health sectors are reticent to share individual level data, citing privacy concerns. While these concerns can usually be alleviated with a good MOU, sometimes parties may not come to agreement. If data sharing of names for in-reach is an insurmountable obstacle, consider one of the following.

  • Create a predictive tool based on information from a match that uses de-identified data.
    Example: The triage tool used in the 10th Decile Project Economic Roundtable Crisis Indicator in Los Angeles, CA
  • Use information on stays to make baseline eligibility criteria that can be verified independently.

Convening interagency and multi-sector working group

Step 2 brings together the people in the community and government that you will need to help champion FUSE and make it happen. This requires identifying Local Champions: both those with clout/influence and those who can implement the program.

Identify the key public agencies, policymakers, and community stakeholders and bring them together in  a working group to help adapt the model, assemble resources, track and troubleshoot processes, oversee outcomes, and advocate for the expansion of the model. An essential motivator of the stakeholder group in a FUSE initiative is the concept that the targeted recipients of supportive housing are shared, therefore require a shared solution.

How do you identify a local champion?
Local champions are usually found within public agencies, have influence and can bring other agencies to the table. Various initiatives have found a champion in the corrections system, such as a county sheriff or deputy sheriff. Others have seen support come from the city or county leadership, such as county commissioners. Still others have seen a local homeless or housing department spearhead an initiative. Finally, a foundation funder with a strong community presence can also help spur a FUSE initiative.

Distinguish between those who can provide FUSE the political support it needs and those who have the sway to convene and implement. Those who can bring others to the table and help guide the initiative to fruition can include department of social services staff ; county sheriff or local correctional agency; non-profit organizations focused on housing, services, homelessness or other community leaders.

Forming a stakeholders working group – Who does it Include?
Stakeholders may include local corrections agency, homeless services agency, behavioral health agencies, housing authorities, housing development/finance agencies, budget officials, elected officials, foundations. Below is a sample table of a stakeholder group that meets regularly. One way to solidify commitment to the process is to have each stakeholder group sign a business associates’ agreement committing to their role in the planning process.

PARTNER ROLE
County Social Services Agency Project lead; provides oversight, coordination, and management of stakeholders; quality assurance;
Behavioral Health Agency Leverage relationship to services and providers for behavioral health services; review of clinical concerns
Supportive housing provider Once selected, serves as the project manager; performs outreach, case management/care coordination for program participants. Also obtains housing, arranges for housing inspections, and potentially property management to tenants. Tracks program implementation progress and reports to group
County Criminal Justice Services Provide data for matching, program oversight, policy advocacy, facilitate jail in-reach; provide referrals to program case managers
Shelter leadership Assistance with locating potential program participants, referrals to program case managers, temporary housing while tenant is engaged and housing is located
Housing Authority Can administer vouchers, master lease apartments, provide property management
CSH Technical assistance around program design and implementation, training and peer learning
University Program evaluation, report on outcomes and impacts

Create supportive housing and develop assertive recruitment process

Identify and cultivate one or more supportive housing providers with the capacity, expertise, and willingness to serve the population. Larger communities may want to consider multiple providers to cover different regions, while smaller communities may work with one trusted provider.

Identify housing resources in community
Explore multiple approaches to securing housing by looking to local, state, and federal resources as well as private dollars. Supportive housing funding typically comes from a variety of resources. The following federally funded programs may already exist in your community.

  • Local Resources: Connect with your local Continuum of Care leadership to identify housing opportunities early on. If your community has a Coordinated Entry or Assessment system, you’ll want to start those conversations early on to ensure FUSE participants can be prioritized for housing.
  • State Resources: Some states have funding for supportive housing, and/or create funding opportunities for housing development that can include FUSE. Service funding dollars can come from state behavioral health dollars, in addition to reimbursement for some services from the state Medicaid program in some places: Example: The Connecticut FUSE program, now known as the CT Collaborative Program on Reentry (CCR), funds operating expenses primarily through the state’s Rental Assistance Program, while the mental health agency covers the expenses.
  • that can potentially be used for supportive housing targeting folks with criminal backgrounds. It’s useful to be alert for funding opportunities which usually will specify whether supportive housing is eligible for a given opportunity.
    Example: In Franklin County, OH, the Columbus FUSE program received federal MIOTCRA funding in 2011 to house 25 mentally ill frequent users of the county’s jail and homeless systems.

Finally, the above funding sources can be combined in various combinations, and in fact leveraged funding streams often make for attractive applications. For example, leveraging local supportive services dollars when applying for federal operating subsidies.

Explore service options including traditional supportive housing services plus short-term services enhancements, ACT or Intensive Case Management teams, Critical Time Intervention.

Develop a financial model that outlines the costs and potential sources of funding to provide housing and supportive services at the agreed upon scale (20 – 100 is a good start depending on jurisdiction size, can be driven by matched data results that demonstrate the size of the frequent user population as well).

Seek out philanthropic and or public agency funds to launch effort, and consider focus on financing front-loaded support services and funding for client engagement and in-reach to jails and health system settings.

Proactive engagement
Ensure that the network of providers or lead provider conduct proactive and assertive recruitment/engagement of clients based on list of target population.


Recruit and place clients into housing and stabilize with services

Develop a flow for in-reach, engagement, recruitment and referral to housing. Be sure to have agreement among the stakeholder group. 

What do we mean by “in-reach”?
CSH has long employed this term for reaching people who fall through the cracks of typical homeless system outreach efforts. Frequent users often reside in institutions and may not encounter the homeless system in the typical or expected way. They are not for a population that signs up for new housing opportunities, nor do they seek out programs to make them eligible for various housing opportunities. They need to be engaged “where they are at” and this is often inside a jail,hospital, or shelter.

Entering into both hospitals and jails requires cooperation and, often, pre-existing agreements between service providers and administrators. Additionally, it can be helpful to set up a data exchange, or implement a “flag” in the jail management information system, so providers can know if the individuals they are trying to find are currently incarcerated.

Finally, education and training of the front-line staff of jails, hospitals, and shelters on the program and referring clients to service providers is critical to placement.

“[MeckFUSE] gives you something that the treatment centers don’t do for you, because, for me, this is the longest I’ve been sober in probably 30 years.”
-MeckFUSE Tenant, See video below for more info.


Troubleshoot barriers to housing placement and retention

Continued stakeholder engagement: Convening meetings of the stakeholder group at least once a month for the first 6 months of the program is key. Members can discuss individual clients (by name or not) and troubleshoot barriers. Common barriers can include: access to SSI, access to other public benefits, barriers to housing posed by criminal background, “good neighbor” issues, substance use issues, difficulties with transportation, and need for further resources outside the stakeholder group – such as employment providers, education, etc.

Training and Support - Provide training and facilitate ongoing peer support among providers to share best practices on services delivery and tenant engagement. FUSE is best implemented as a housing first and harm reduction program; training in these areas for the stakeholder group is key.


Track Implementation Progress

Why track?
Setting implementation goals is crucial to having a successful program and to generating metrics that may help identify specific points within the system that need to be addressed. The goals within the implementation phase also lend to the overall success of FUSE.

Goals that should be set include:

  • Housing placement timeline/target dates.
  • Retention goals, such as defining how long do tenants have to stay in housing to be considered a “success”

Metrics to track include:

  • Number of referrals per week or month
  • Time between engagement and housing – this is a great learning opportunity to determine if and what in the process needs to be corrected. For example, if clients’ applications for housing are taking the housing authority too long to approve, these data will prepare providers for a discussion to help remedy the issue.
  • Demographic aspects of clients
  • Interactions with criminal justice system after housing
  • Hospitalizations, emergency room use after housing
  • Primary care engagement after housing
  • Access to benefits, such as SSI and Medicaid
  • Access to employment and employment services/training opportunities
  • Engagement with treatment/recovery options
  • Opportunities/attendance for social engagement
  • Landlord issues and disputes

 


Measure outcomes/impact and cost-effectiveness

Measuring outcomes is critical to making the case to keep the program running and to bring it to scale. Without clear metrics that outline the impact and cost-effectiveness of the program, it is difficult to maintain the political will and support that has been present through program implementation.  While rigorous evaluations that incorporate control/comparison groups can be expensive, they can be enormously helpful in convincing stakeholders to invest in expanding a FUSE program. Importantly, much of the impact of a FUSE initiative comes in reduced system use of shelters, jails, and health care. To the extent that a community can measure reduced use through access to administrative data, any study will be strengthened.


Enlist policymakers to bring FUSE to scale

Several communities are looking for ways to bring FUSE and other high utilizer or superuser initiatives to scale. They are doing this in various ways, including implementing Pay for Success initiatives and advocating for Medicaid to finance supportive housing services. Read more about these efforts here.


Expand model and house additional clients

Using the metrics you now have that demonstrate program success, work with policy makers and agencies to implement systems change and create more permanent resources within the community to support an expansion of FUSE. CSH has worked with several communities that have expanded FUSE in various ways.

Case studies where communities have significantly expanded FUSE pilots:

 

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